Fillable BACKFLOW PREVENTION ASSEMBLY TEST & MAINTENANCE REPORT (City of Garden Grove)

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BACKFLOW PREVENTION ASSEMBLY TEST & MAINTENANCE REPORT (City of Garden Grove)

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City of Garden Grove – Public Works Department
Water Service Division – Water Quality Section
13802 Newhope St, Garden Grove, CA 92843
TEL (714) 741-5395 FAX (714) 638-9906
EMAIL cross.connection@ggcity.org
BACKFLOW PREVENTION ASSEMBLY TEST & MAINTENANCE REPORT
Name:
File #:
Seq#:
Attn:
Address:
City, State, Zip
Meter Serv Protection?
Email:
Yes No
Service
Location:
Device
Location:
Mfg/Model/Type:
Size:
Serial #:
This is a Replacement Assembly This is a New Installation This is a Lead Free BFP
REDUCED PRESSURE PRINCIPLE
ASSEMBLY
Line Pressure
DOUBLE CHECK ASSEMBLY
INITIAL
TEST
Check Valve #1
Check Valve #2
Relief Valve
PVB/SVB
Held at PSID
Tight Leaked
Held at PSID
Tight Leaked
Opened at PSID
Did NOT Open
Air Inlet
Opened at PSID
Did NOT Open
Opened fully?
Yes No
Check
Valve
Held at PSID
Tight Leaked
REPAIRS
CLEANED .......
REPLACED .....
DISC................
SPRING ..........
GUIDE .............
HINGE PIN ......
SEAT ...............
MODULE .........
OTHER ............
DESCRIBE:
CLEANED ........
REPLACED ......
DISC ................
SPRING ...........
GUIDE .............
HINGE PIN .......
SEAT ...............
MODULE..........
OTHER ............
DESCRIBE:
CLEANED ........
REPLACED .....
DISC ................
DIAPHRAGM ...
FLOAT .............
SPRING ...........
O-RING(S) .......
MODULE .........
OTHER ............
DESCRIBE:
CLEANED .......
REPLACED .....
DISC ................
DIAPHRAGM ...
FLOAT .............
SPRING...........
O-RING(S) .......
MODULE .........
OTHER ............
DESCRIBE:
FINAL
TEST
Held at PSID
Closed Tight
Held at PSID
Closed Tight
Opened at PSID
Air Inlet:
Opened at PSID
Opened Fully? Yes No
Check Valve:
Held at PSID
Comments:
Initial
Test
Date:
Signed:
Tester #:
Print:
Pass Fail
Phone:
Final
Test
Date:
Signed:
Tester #:
Print:
Pass Fail
Phone:
Send Report To: Copy To:
cross.connection@ggcity.org ocbackflowtests@ochca.com
CLEAR
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BACKFLOW PREVENTION ASSEMBLY TEST & MAINTENANCE REPORT (City of Garden Grove)

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Completed 30 May 2021

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